Nursing staff interactions during the older residentsŁ transition … · 2017. 4. 10. · Schumacher [19] suggest integrating concepts of complex adaptive systems from complexity

Eika et al. BMC Health Services Research (2015) 15:125 DOI 10.1186/s12913-015-0818-z

RESEARCH ARTICLE Open Access

Nursing staff interactions during the olderresidents’ transition into long-term care facility ina nursing home in rural Norway: an ethnographicstudyMarianne Eika1,2,3*, Bjørg Dale4,5, Geir Arild Espnes1 and Sigrun Hvalvik2,3

Abstract

Background: Future challenges in many countries are the recruitment of competent staff in long-term care facilities,and the use of unlicensed staff. Our study describes and explores staff interactions in a long-term care facility,which may facilitate or impede healthy transition processes for older residents in transition.

Methods: An ethnographic study based on fieldwork following ten older residents admission day and their initialweek in the long-term care facility, seventeen individual semi-structured interviews with different nursing staffcategories and the leader of the institution, and reading of relevant documents.

Results: The interaction among all staff categories influenced the new residents’ transition processes in variousways. We identified three main themes: The significance of formal and informal organization; interpersonalrelationships and cultures of care; and professional hierarchy and different scopes of practice.

Conclusions: The continuous and spontaneous staff collaborations were key activities in supporting quality care in thetransition period. These interactions maintained the inclusion of all staff present, staff flexibility, information flow tosome extent, and cognitive diversity, and the new resident’s emerging needs appeared met. Organizational structures,staff’s formal position, and informal staff alliances were complex and sometimes appeared contradictory. Not all thestaff were necessarily included, and the new residents’ needs not always noticed and dealt with. Paying attentionto the playing out of power in staff interactions appears vital to secure a healthy transition process for the olderresidents.

Keywords: Long-term care facility, Staff interactions, Transition, Complexity science, Resident, Ethnography

BackgroundIn developed nations, there is an expected increase inthe number of older people above the age of 67 [1]. InNorway the number of people above the age of 80 isestimated to double over the next 35 years. Due to theincreasing number of older frail people and a decrease inthe number of people to take care of them, there is agrowing concern for the future recruitment of competent

* Correspondence: [email protected] of Social Work and Health Science, Faculty of Social Sciencesand Technology Management, Norwegian University of Science andTechnology (NTNU), 7491 Trondheim, Norway2Telemark University College, Faculty of Health and Social Studies, Post box203, NO-3901 Porsgrunn, NorwayFull list of author information is available at the end of the article

© 2015 Eika et al.; licensee BioMed Central. ThCommons Attribution License (http://creativecreproduction in any medium, provided the orDedication waiver (http://creativecommons.orunless otherwise stated.

nursing staff to nursing homes [2,3]. Older people in long-term care facilities (LTCFs) have complex medical andcare conditions [4,5] and require competent care. Inter-nationally, in contemporary health care environments forthe elderly, the employment of unlicensed staff in directpatient care is on the increase [6,7]. Researchers [6] havenoted that there has been a paradigmatic shift in staffingoutcome literature from “an individual to team mindset”(p 10), emphasizing teamwork and inter-professional col-laboration. Harris and McGillis [6], conclude that adminis-trators and researchers need to pay attention not only toskill mix and numbers of staff, but also to processes ofinteraction between patients, providers and organizations.

is is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andiginal work is properly credited. The Creative Commons Public Domaing/publicdomain/zero/1.0/) applies to the data made available in this article,

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Eika et al. BMC Health Services Research (2015) 15:125 Page 2 of 12

Staff interaction plays a role in the quality of care toolder people in nursing homes [8-10], and the challengesare to use the available personnel in the best possibleways to promote good quality care. There are no na-tional guidelines for formal staffing levels in nursinghomes in Norway [11]. Yet, the licensed staffing levelsare relatively high, compared to other European coun-tries [12]. According to a study of 12 nursing homes in 4of the largest municipalities in Norway [13], registerednurses constituted 24,1% of the workforce, auxiliaries46,3%, and unlicensed assistants 29,6% on weekdays.During weekends the unlicensed assistants constituted47,6% of the workforce. Varieties of primary nursing sys-tems are used in many Norwegian nursing homes. Theprimary nursing care delivery model [14], support apatient-centered nurse-patient relationship that pro-motes continuity of care. Each patient is assigned oneprimary nurse who assumes responsibility and authorityto “assess, plan, organize, implement, coordinate, andevaluate care in collaboration with the patients and theirfamilies” (p 295).Moving into LTCF is a stressful change [15-17] for

older residents and their family members, and can be as-sociated with the concept transition defined as a passagebetween two relatively stable periods of time where theperson moves from one life phase, condition or status toanother [17]. It refers to processes and outcomes ofcomplex person-environment interactions [18]. A transi-tion may be triggered by a change or marker event,which may bring a period of upheaval and disequilib-rium for the person (s) involved. Nursing research show[17] that transitions may connect with uncertainty, emo-tional distress, interpersonal distress and worry. Needsmay not be met in familiar ways and changes in the per-son’s self-perception and self-esteem are common. Tran-sition theory in nursing is useful in the development ofnursing therapeutics to facilitate the transition thatpeople undergo. According to Meleis et al. [18], nursingtherapeutics involves nursing strategies during transitionenabling the nurses to anticipate points at which theperson is most likely to reach peak of vulnerability, andselect “the most fruitful kinds of action and optimalintervention points for achieving the desired healthmaintenance or health promotion goals” (p 29). Possibleinterventions include continuous assessment, reminis-cence, role supplementation, creation of a healthy envir-onment, and mobilization of resources [17]. Geary &Schumacher [19] suggest integrating concepts of complexadaptive systems from complexity science to connect thetransitions to the context in which they are occurring.Transition is a process, not a change that occurs in amoment of time [18,19], and complexity science [19],“illuminates the nature of the transition process andchanges that occur while a transition is unfolding” (p 241).

During interactions, new processes or patterns of inter-action, as well as new outcomes, emerge. Concepts sug-gested [19] are multiple individual agents interactinglocally in a dynamic non-linear fashion, relationships, self-organization, emergence, and culture and environment ofall agents. Self-organization refers to new behaviors ornew patterns that emerge from individual agents’ reactionto changes within the complex organization. Althoughself-organization “appears to be planned within thesystem, it is actually the reaction of an agent or a group ofagents to change made by another. With the newinformation, agents, acting on established rules, changetheir behavior, leading to a new structure” ([19], p 239).Emergence refers to changes that are not predictablefor two reasons, the absence of a complete context, andthat interactions between persons are nonlinear.This paper is part of a larger study exploring and

describing the transition of older people into LTCF in anursing home in southern rural Norway from the per-spective of next-of kin and staff. In our first study [16],we explored the experiences of next-of kin during theirolder family members’ transition into LTC-placement. Inthe second study [20], we explored and described differ-ent nursing staff ’s actions during the older residents’initial transition period in the LTCF. This present studyfocuses on staff interaction based on the same ethno-graphic data as in the second study. Literature exploringstaff interaction within residential long- term care forthe elderly has different perspectives and foci. One studyexplores the challenges between licensed and unlicensedstaff working together [21], others explore and supportthe empowerment of direct care workers [8,22], and yetothers explore and describe interaction patterns amongall nursing staff [10]. We have been unable to find stud-ies dealing with licensed and unlicensed staff interac-tions during older residents’ transition into LTCF.The aims of this study were to explore and describe

the nursing staff interactions during the older residents’transition into LTCF, and how staff interactions mayinfluence their assistance and care for the older residentsin transition.

MethodsAn ethnographic design helped gain in-depth understand-ing of staff interaction in contexts [23,24]. Humans are so-cial beings whose actions, opinions and self-understandingare influenced by context, and influence back on context[25]. The ontological position taken was constructivist[26] with an analytical middle ground between reality andrepresentation. In the hermeneutical tradition of Gadamer[27], the concepts horizon and prejudices closely link withthe identification of the researchers’ pre-understandings aspart of exceeding one’s horizon. It posed challenges thatthe authors have a background as registered nurses with


an interest in the care of older people. While our precon-ceptions and knowledge could give an easier understand-ing of what was going on, we could also become toofamiliar and understand too quickly. Daily critical reflec-tion during the participant observation periods and inter-views helped to use our preconceptions in critical andconstructive ways [27,28].Rigor was established by the time frame of the study,

and by using multiple methods in data collection. Theanalysis was undertaken in collaboration with an experi-enced researcher in qualitative methods.

Data collection, context and participantsThree sources of data were used; periodic participantobservations, interviews and reading of documents. Peri-odic participant observation periods following ten newresidents on admission day and the initial week wereperformed, commencing early June 2011 and endingJanuary 2012. The head nurse contacted the researcherabout the expected arrival of a new resident. The re-searcher was present in the LTCF during the preparationperiod before the resident arrived, on admission day andthe first week. The selection of staff participants weremainly those who were appointed primary contacts forthe new resident, and those they interacted with. Theparticipant observations were carried out to get insightsinto staff ’s interactions in different settings such as mealsituations, new residents’ morning care and oral shiftreports, to name a few. The researcher was in the facilityduring daytime and afternoon shifts weekdays, weekendsand summer holiday. Writing memos was carried out assoon as possible after something had taken place. Whenthe researcher did not directly participate, for instanceduring a meal or a shift report, notes were taken as theevent evolved. This strategy was used when the staff hadbecome familiar with the researcher’s presence. Further,the researcher’s reactions and reflections were writtendown daily to identify prejudices and role confusionsbrought to the study. These intermittent periods posedchallenges both for the researcher’s own role under-standing, and in ensuring that all the staff involved inthe study at any given time were informed about the re-searcher’s role, and the purpose of the research project.The sporadic participant observation periods opened upto perform some of the semi-structured interviews in-between. This combination helped clarify issues that wereunclear, and directed the subsequent observation periodsand semi-structured interviews. The written material suchas the individual plan on the computer, the care plans inthe residents’ bathrooms, and daily written reports wereconsulted [29], mainly to confirm and augment data fromother sources. Individual semi-structured interviews withseventeen staff members comprising four nurses, six auxil-iaries, five assistants, the head nurse, and the leader of the

institution were carried out in a small room in the nursinghome outside of the LTCF. The recruitment of the respon-dents to the formal interviews were by voluntary participa-tion, and some were headhunted by the researcher as thestudy went on. Each interview lasted an hour on average.The interview guide had questions about how staff inter-acted with colleagues during the preparation period, ad-mission day and initial week after arrival. The first authorattempted to follow what the respondents themselvesassociated and found relevant to talk about relating tothis topic. The interviews were audio recorded andtranscribed as soon as possible after they had takenplace. The weekly periodic participant observationsopened up for the researcher to have informal conver-sations with the new residents, and this influencedfurther fieldwork and the analysis.The nursing home is situated in rural southern

Norway. The LTCF consists of thirty private rooms splitinto three units each with ten private rooms. The nurs-ing staff comprises licensed registered nurses (nurses),auxiliaries (auxiliaries), and unlicensed care assistants(assistants). The nurses have three years’ nursing educa-tion from university/university-college and the auxiliar-ies have two years’ training in high school [30]. Theunlicensed assistants were not educated in health careapart from short courses at the workplace. The partici-pants were females with two exceptions. The age rangedfrom early 20s to early 60s, and the length of employ-ment varied from a few weeks to more than 30 years.Staffing ratios and mix varied with the shifts, weekdaysor weekends, and holidays. During daytime on weekdays,the staffing was three staff to ten residents, and usuallythere was one nurse to ten residents or sometimes onenurse to five residents. The auxiliaries or assistants ratiowas one staff to three or four residents. In the evenings,there were usually two staff (auxiliaries or assistants, orboth) in each unit and one nurse in charge of the facility.In addition to permanent licensed and unlicensed staff,there were part-time supply assistants who workedweekends only. All staff categories performed directresident care. The care was organized according to a pri-mary nursing model [14], meaning that in this LTCF thenurses were responsible for five residents each, and theauxiliaries normally shared responsibility with the nursein each unit for three residents each.

Data analysisThe first author immersed herself in the transcribedinterviews and field notes as the study went on and afterthe collection of data was over. Writing is a key partof the entire research process, and closely related toanalysis [23].Writing things down during the fieldworkand interview periods, and then writing things up [24]helped in this endeavor. The interview texts and the


fieldwork texts were treated as texts equally important[31]. Sensitizing concepts suggested further directions inwhich to look, and gave us “a general sense of referenceand guidelines in approaching empirical instances ([23],p 164, based on Blumer [32]). Some concepts were “thephysician’s round”, “primary nursing”, “open door” and“chameleon.” The written documents were consultedmainly to check our understanding of the data from theinterviews and the fieldwork [29]. The data were readrepeatedly and in different ways to get different versions[23,33]. The parts of the transcribed interviews and fieldnotes dealing with the same issues were taken out of thecontexts in which they occurred, to help get hold of thedifferent versions of the same phenomenon [33]. For in-stance, “spontaneous staff interactions” was connectedacross the data material. The researchers also searchedfor theoretical perspectives that helped make sense ofthe emerging patterns [23,24] central to the aims. Wethen checked if what we had interpreted from the mater-ial taken out of context was in accordance with the con-texts where they occurred [33]. If not, we started all overagain. The emerging themes were further explored toclarify their meaning and explore their relation to otherthemes. The sub-themes show the variations containedin each theme.

Ethical considerationsThe Regional Committees for Medical and Health Re-search Ethics in southern Norway approved the project(REK 2011/153b). Formal access to the field was grantedthrough the health care authorities in the municipality.Participants were assured confidentiality, informed thattheir participation was voluntary, and that they had theright to withdraw at any time without stating a reason.Written informed consent was obtained from all staffparticipating in the interviews, and all agreed to theinterviews being recorded. A staff information meetingwas arranged prior to the fieldwork. Residents wereasked orally and in writing if they accepted that the firstauthor participated in their daily care in the first weekafter arrival. Eight residents consented while two resi-dents were considered cognitively impaired, and next-ofkin consented on their behalf.

ResultsThe analysis consists of three overall themes with severalsub-themes, which illuminate how staff interacted duringthe older residents’ transition into LTCF, and possibleinfluence on patient assistance. The following identifiedoverall themes: The significance of formal and informalorganization; interpersonal relationships and culturesof care; professional hierarchy and different scope ofpractice. The themes overlap and intertwine in complexways.

The significance of formal and informal organizationThe staff interactions appeared modulated by the pri-mary nursing model, the head nurse management style,and staff mix at different shifts. Their interactions wereinfluenced by, and influenced back on, individual actionsand team work, and information flow.

Individual actions and team workOften the staff in the small units appeared to interactcontinuously while assisting and assessing the newresidents. They acted in coordinated ways with their col-leagues regardless of professional level while attemptingto adapt to the new resident’s evolving needs. Yet thestaff interactions were to a certain extent characterizedby the understanding of their work as individual actions.Due to the primary nursing model, most licensed per-manent staff were responsible for three to five residentseach. They attempted to cater for most aspects of thenew resident’s needs, and this ambition put pressure oneach staff member. For instance, one primary nurse wasat work on her day off to talk to family members after anewly arrived resident had died. In addition, a part-timeprimary nurse wanted to get an overview of all the resi-dents in the facility, and thus worked extra. The nursesclaimed that the primary nursing model in each unitmeant that no nurse had an overview of all the residentsin the facility. Furthermore, those who chose to workpart-time, on average in eighty percent positions, did soto have the strength to do a proper job. If they consid-ered their job well done, it gave them energy to accom-plish the little extra for the new residents and theresidents in general.Connected with the notion of total responsibility for

the new resident, the staff viewed their own work andthat of each other differently. Many auxiliaries felt thatthey knew more about the new residents’ overall needsinitially than the nurses, because the nurses had so manyother tasks to perform in this period. It appeared in theinterviews and the participant observation periods thatmost nurses regarded it as self-evident that they knewmost about the new residents’ psychosocial as well asmedical needs. They argued that even though they hadmany different tasks to perform initially, they still spenta lot of time with the resident in the small units. Inaddition to many fragmented tasks to perform concern-ing the new residents, the nurses had to prioritize thoseresidents in most need. Sometimes this was at the expenseof interacting and collaborating with staff colleaguesduring the shifts, and could restrict their face-to-faceinteraction with the new residents.The primary contacts, the nurses and auxiliaries, had

authority among the staff, and few colleagues wanted tointerfere. In their absence, some were reluctant to perform


independently towards the new resident, illustrated by thefollowing:

When the primary nurse was on sick leave, anothernurse was responsible for that unit. She did notestablish documentation areas in the computer careplan, and argued that she would not interfere with theways her absent nurse colleague worked. This made itdifficult for the other staff to document in thecomputer program the first days after the resident’sarrival (fieldwork observations).

During evenings, week-ends and holidays, the mix ofstaff could disturb the primary nursing arrangement,illustrated by the following:

If only supply staff worked in one unit during a shift,the primary auxiliary could be transferred from herunit to compensate for the shortage of licensedpersonnel in the other unit. This was frustratingbecause she did not have the chance to follow up thenewly arrived resident as well as she would have liked(summary of parts of interview with auxiliary).

These circumstances disturbed the permanent staff ’swork rhythm with their primary residents. Some foundsupply staff a nuisance to work with mainly because ofthis.In these periods with many part-time supply staff at

work, the care appeared crudely performed. It seemedthat the regular staff helped the new residents to settlein, while some of the new residents withdrew with manysupply staff at a shift:

Even though many residents preferred to spend timein their rooms between meals, it was exceptionallyquiet in the units at shifts with many supply staff atwork. It seemed the cognitively able new residentsquickly learned to take after the other residents’strategies at these times; after the meals, they wentinto their rooms and shut the door behind them(fieldwork observations).

The head nurse (HN) attempted to support each staff ’sself-confidence and self-reliance in their interaction withthe residents, “to make them aware how much each oneof them matters” (interview HN), and she kept her dooropen when she was in her office. It varied among thestaff how they related to this. Some consulted herfrequently, while others said that the HN was often awayat meetings. Still others, like the week-end supply staff,never had the opportunity to interact with the HN inthis way. This management style encouraged individualstaff to develop a relationship with the new resident at

their own speed. Furthermore, it seemed to legitimizethat the staff nurses managed their units differently. Thiscould cause problems particularly for the nurse incharge of a night or weekend shift, who had responsibil-ity across all three units. For instance, written informa-tion on paper about the new resident was stored indifferent places in the three units, and the nurse incharge spent a long time before she found the papers.

Information flowThere was a dominant oral culture in the LTCF and itsunits, and face-to-face communication was the mostcommon. Often the unit staff interacted spontaneouslyby sharing information and brainstorming together tohelp the new resident. Some staff could dominate in theoral culture irrespective of formal position, which frus-trated some assistants:

As unlicensed staff it is very difficult – eh it oftenhappens that you are trapped between two who havestrong opinions about how to care for the newresident, right? Eh, sometimes one feels like achameleon - that one goes into the roles of those oneworks with at any given time (interview assistant).

This assistant frequently consulted the HN when shewas available, and these interactions contributed tostrengthening her self- esteem and belief in her ownskills.Particularly the auxiliaries and assistants perceived

that they had neither the time nor the calmness to readabout the new resident in the computer program “whilecolleagues were toiling in the units” (interview auxiliary).Some were apprehensive that their colleagues couldinterpret sitting at the computer as avoiding work.The assistants felt that they sometimes lacked infor-

mation about the new resident, and how to performtheir work. They had some initial training in the facilitybefore they started, but had to tackle many things adhoc. They generally wished the permanent staff toinform them better. “It is easy to forget to informcolleagues when one has been working for a while, andknows one’s way around” (interview assistant). Someassistants admitted that they should ask when in need,but were afraid of asking about something they believedeverybody knew, and sometimes they did not knowwhat to ask about. The potential consequences for thenew residents were that everyday basic needs andobservations were unnoticed, or if noticed, would not bepassed on to colleagues. The assistants’ lack of knowledgeabout the new resident’s needs could be uncomfortable,for the new resident and the assistants, illustrated bythe following:


It was during one of the first shifts I worked aftersome time off and I assisted a new resident whom Idid not know. I just poured milk into his glass andgave it to him. He coughed a lot and I was afraid hewould choke. I learned afterwards that he should havehad “Thick and Easy”, instant food thickener, added tohis milk to make it easier for him to swallow. Nobodytold me and it was not written anywhere – so suchthings are easily forgotten and taken for granted thateverybody knows ……..so poor resident, he coughedand hawked during the entire breakfast (interviewassistant).

This assistant read about the new resident when shearrived back at work after some days off, and discoveredthat this important piece of information was unwritten.It appeared to be an attitude among many staff thatit was little point in reading, which again seemed toencourage an attitude of writing less. Furthermore, thepermanent licensed staff, particularly the night shift staff,could lack information about the new resident. At theoral shift reports staff did not have the time to report allaspects of the new resident’s condition and needs to thestaff at the next shift, and the next shift staff did notalways read the new resident’s individual protocol:

The night shift staff was unaware that the newresident was incontinent for feces, and did not lookinto his room during the night rounds. Thisinformation was not passed on at the oral shift report,but was written in the computer care plan. Since thenew resident did not want to disturb the night staff,he tried to manage on his own. He made a mess andfelt very bad about it. He had poor vision and it wasdifficult for him to tidy up after himself, and he neededhelp. Regarding this resident, the oral interactionsamong staff in the initial period did not focus on hisphysical shortcomings (fieldwork observations).

The taken-for-granted attitude among permanent staffcombined with little or no writing or reading, made iteven harder for the staff in need of information aboutthe new resident. There were serious consequences forthe new resident. Even though the staff could adjust tothe new resident’s evolving needs, the care could also bebased on general principles of care instead of tuning into the new resident’s particular needs and preferences.For some new residents the unpredictability of theassistance was disheartening.

Interpersonal relationships and cultures of caringThe staff interactions were influenced by, and influ-enced, intra- and inter -professional collaboration, per-sonal traits and attitudes, and professional authority.

Alliances and collaborationStaff collaboration appeared strong in intra- professionalalliances. The general pattern was that individual staffappreciated working with people similar to themselves,and some met each other in their spare time. Typical formost alliances was a need of sparring with partners withthe same values and outlooks of good patient care.Having a partner (s) helped the individual staff stick totheir ideals and norms. Some felt they could accomplishmore, and exploited the shifts they worked together todo it their way and accomplish little extras such asbringing strawberries for the afternoon coffee. The nursealliances helped to strengthen their belief in their ownprofessional judgments, and influenced their authority.Those who were not so strongly involved in alliancessaid that they felt insecure and inferior to some authori-tative nurse colleagues.The alliances seemed to influence the assistance of the

new residents in different and unpredictable ways. Someallies focused on the new resident’s emerging needs andattempted to assist in their best interest, while otherswould rather “satisfy your relationships with colleaguesthan assist the residents (interview nurse).The staff also collaborated inter-professionally, and the

primary nursing arrangement in the small units encour-aged such interactions. Yet it seemed to some extent todepend on individual staff and those working together atany given time. For instance, the collaboration betweenthe assistants and the other staff appeared to depend onperson. Some assistants seemed to have more authoritythan others, and be more part of the unit team. Mostly,the assistants kept in the background in staff interac-tions, and permanent staff appeared to make few effortsto include them in discussions about the new resident.Regardless of alliances, most permanent staff missed

regular formal meetings. The meetings were cancelledmainly because key persons such as the nurses were ab-sent, or too busy. Some auxiliaries claimed these meetingswould provide them with the same medical informationfrom the nurses about the new residents, and make themmore confident in their observations and assistance of thenew residents. In addition, the auxiliaries appreciatedbeing in a setting of dialogue and discussions, whereeverybody had the chance to participate.

The privacy of caringSome auxiliary allies were strongly involved with the res-idents and provided extras such as making cookie doughat home for the residents to bake, bringing local poetryto read, and arranging parties. Full-time employees andnurses with their professional focus had neither the timenor the energy to be so involved in these activities. Thehead nurse attempted to even things out, so that every-body felt their work appreciated. Most new residents


appeared at ease participating in familiar everyday activ-ities. One new resident was provoked, however, whenasked to participate in the baking of Christmas cookiesthe day after he had arrived. He claimed the activity wasa fake. He had other needs at this time, such as gettinghelp with his diahorrea, and come to terms with beingin the LTSF (field observations).

Professional hierarchy – different scopes of practiceThe staff interactions were influenced by, and influencedback on, the professional hierarchy and the differentstaff ’s perceived responsibility and work domains.

Hierarchy and responsibilityThe staff awareness of the professional hierarchy varied.The assistants talked about “being at the bottom” whilethe auxiliaries expressed that “we are not so high up inthe hierarchy”. The nurses did not explicitly talk aboutit, but appeared self-conscious about being the leaders.Some assistants seemed comfortable with not having

the same responsibility as the others. The danger wasthat they took for granted that the licensed staff knewwhat they knew, and would see to it. Some did notreport obvious everyday observations about the newresidents, which may be considered negligence on theirpart. One assistant said that she sometimes kept quietwhen she knew something about the new resident thatthe permanent staff did not know, because she was “onlyan assistant” Illustrated by the following:

When two staff had to assist the new resident in themorning care, the assistant knows in detail how thenew resident prefers his assistance because she hashelped him in previous morning care situations. Thelicensed nurse/auxiliary, however, may assist theresident for the first time, and she is paying littleattention to the resident’s preferences and abilitiesand the assistant’s knowledge and experience(summary part of interview assistant).

Moreover, the assistants believed that if the permanentstaff regarded them as incompetent they might lose theirjob. The fact that many permanent staff appeared not toexpect the assistants’ participation in discussions aboutthe new resident could reinforce the mechanism of assis-tants being exempt from responsibility. One assistant feltpersonal responsible and would have appreciated infor-mation from the permanent licensed staff. For instance,she had to ask to get supervised in the Heimlich maneu-ver, which is a technique for preventing suffocationwhen a person’s airways become blocked. She had expectedthe permanent staff to inform her about that.

Monopoly of medical knowledgeIt appeared as self-evident for the management and mostnurses that the nurses and the physician had the monop-oly of the body of medical knowledge. The physicianexpected the nurses to prepare his once-a-week roundproperly, so that he could perform his work efficiently.This could keep the nurses away from interaction withcolleagues and the new resident in the initial transitionperiod. The primary auxiliaries perceived this round as a“secret meeting” between the physician and the nurses:

We are not nurses and we are not physicians, and weknow that, and I believe we do not trespass into theirprofessional territories. I believe we are very consciousabout that. Yet we are knowledgeable, but we arenever asked. The physician never asks us aboutanything. If the staff nurse is absent, a nurse fromanother unit who does not know the residents joinsthe physician on his round. I think we could havedone that, too. We auxiliaries are, however, not highup in the hierarchy. I like my job and I do my bestand don’t care if I am not so high up there. I havecollaborated with the occupational therapist and shelistens to us and acts on our observations. Wecooperate well and find the best solutions together”(interview auxiliary).

This quote illustrates an attitude among many auxiliar-ies that good collaboration was to “find the best solutionstogether” regardless of professional position. Moreover,many connected staff collaboration with knowing one’slimitations: “Residents trust us when they know that staffcooperate well and know their limitations” (interviewauxiliary).Many auxiliaries, assistants and supply staff would

have appreciated that the nurses supervised them orallyafter the physician’s round. Sometimes this happened,but was not a pattern. The nurses seemed to have differ-ent opinions about the auxiliaries’ involvement in med-ical matters. Some stressed that “If one wants to helpthe patients in the best possible ways one has to involveeverybody who is together with the patient” (interviewnurse), and argued that it was unrealistic for the nursesto manage all the follow-up on their own. Not all thenurses or the management seemed to share this view.When a new resident arrived, the nurse presented her-

self to the resident and his/her family as the sole primarynurse, and omitted mentioning the primary auxiliaries. Ifthe next-of-kin asked for information about their olderresident, the primary auxiliaries were frustrated whenthey had to direct them to a nurse who might not knowthe resident at all but knew the resident’s medical situ-ation. The consequences for the new residents could bethat critical observations and knowledge about their


everyday needs, preferences and medical condition wereignored initially.

DiscussionThe aims of this study were to explore staff interactions,and how the interactions may influence the care of theolder residents in transition into LTCF. The findingsreveal complex staff interactions, and suggest that thisinfluenced how they assisted and cared for the newresident.The HN’s relationship-orientation seemed to encour-

age individual staff in their interaction with her, and thenew residents. She appeared to create a climate thatinspired possibilities and safety among the permanentstaff. We wonder, however, if sometimes her involve-ment with individual staff could impede the team inter-actions. When the HN was available it seemed easier forindividual staff to discuss their imminent concerns aboutthe new residents with her. These interactions appearedto give individual staff authority among the other staffsince they had consulted the head of the facility. Accord-ing to studies [10,34,35], management support of goodrelationships among staff such as building connectionsand developing existing strengths, contribute to thedelivery of better resident care and foster staff inter-dependence. The HN attempted to balance structuresand routines with building individual staff ’s self-confidence in spontaneous interactions with the newresident. This management ideology may connect withcomplex adaptive system’s theory. According to Pen-prase & Norris [36], this theory frees nurse leaders froma management that prescribe behaviors that stress pre-diction and control, to behaviors that aim to build strongrelationships with the freedom to produce creative out-come. “Allowing teams to form on their own encouragesa culture of care and connection in which staff arehighly responsive to the needs of their units“(p 128).Transition theory in nursing [18], also underscores thatthe agents react to the emergent changes in flexible anddynamic ways. Still, the HN’s balanced approach ap-peared contradictory, at the same time as the HN pro-vided feedback and praise to mainly the permanent staff,this individual staff focus could contribute to less focuson staff interactions that promoted good quality care.Research suggest [10] that “managers should scan theirfacility for existing pockets of excellence, to discover,support and expand staff interactions and relationshipsthat already promote better performance” (p 13).The arrangement with the primary nursing model

influenced staff interactions in complex and at timescontradictory ways. This way of organizing the worksupported the dynamic, inter-professional staff collabo-rations among the primary contacts, where staff discussedtheir observations and uncertainties concerning the new

resident. Still, each primary contact was assigned their rolein the primary nursing teams. This organization appearedto legitimize that some did not fully involve themselveswith each other and the new residents at shifts where theprimary nurse and auxiliaries were absent. Needs consid-ered unnecessary to deal with immediately, were left tothe primaries to take care of when they were back at work.Research regarding the relationship between the primarynursing model and the quality of care is inconclusive [14].Furthermore, the findings suggest that the primarynursing arrangement contributed to gluing the primar-ies to their individual responsibility beyond their paidwork responsibilities.The staff in the units also formed their own teams.

Often, in these situations, everybody contributed regard-less of professional competence, and noticed and assistedthe new residents’ emergent needs. This can be associatedto research pointing at physical infrastructure [37] as onenecessary component for successful staff collaboration.Each unit was small and encouraged the staff to continu-ously interact and complement each other. While thenurses focused predominantly on the new residents’medical condition, the enthusiasts provided good care in ahomelike atmosphere. According to a study [38], qualitycare comprises attention to psychological and social needsalong with medical considerations.Moreover, Geary and Schumacher [19] argue that open

boundaries between the agents “provide the potential forinteractions that enable self-organizations, sense-making,and emergence of agent-specific processes and outcomes”(p 244). Our findings suggest that at some times, in somesituations and depending on persons involved, boundarieswere more open than at other times. It appeared that thespontaneous interactions per se contributed to creatingopen boundaries among the staff. Leykum et al. [39],found in their analysis of eight observational and interven-tional studies that how individuals self-organized was notnecessarily done according to hierarchy or organizationalstructure but “based on how the work is actually accom-plished” (p 2). In our study, the staff self- organizationappeared based on structural features as well as how thework was carried out.The arrival of a new resident in the LTCF and particular

unit changed the work environment. Literature [40] hasidentified key practices that allow organizations to adaptsuccessfully to such changes. One is to let information flowspontaneously among all agents. Our study focused onstaff as agents, and although information at times flowedspontaneously among them, the findings also demonstrateotherwise. The lack of medical knowledge among theauxiliaries and assistants and sometimes the nurses’ lackof personal involvement and knowledge about the newresidents’ everyday needs could contribute to fragmentedunderstandings and resident assistance during this period.


Aspects of authority and power within the LTCF influ-enced staff interactions, and the findings disclose intri-cate power mechanisms at play. The oral culture allowedsome to dominate, between staff groups as well as withinstaff groups. Eloquent persons got their opinions through,sometimes at the expense of sound professional know-ledge and colleagues’ well-being. Being a member of analliance gave some power and authority, sometimes at theexpense of others, and staff collaboration on a more gen-eral level was disrupted. The unlicensed staff were oftennot fully involved in the staff collaborations and discus-sions about the new residents. Not being involved mayhave negative consequences in several ways. This is inaccordance with studies [40,41] which show that well- in-formed and supervised nursing assistants perform bettertowards patients.Some permanent staff considered the unlicensed staff

a nuisance to work with, and did not expect theirparticipation. Jacobsen [42] also found that the assistantswere a “fellowship of those who have no say” (p 86). Forinstance, during meals [20] with many cognitively ableresidents the local staff ’s involvement with the new resi-dents could shut the weekend supply staff off from par-ticipation. The enthusiastic allies were good at what theywere doing and the supply staff could feel redundant.That the assistants kept a distance in staff interactions,may also suggest that this legitimized their at times poorinvolvement with the new resident. The licensed staffmay have to compensate for the assistants’ limited con-tributions towards the new residents, or as the findingssuggest, some needs were ignored. Many auxiliaries han-dled the distance and difference from the nurses andthemselves by the appreciation of the homelike, everydayactivities, where the nurses also participated; here every-body was of equal worth. According to Gullestad [43],sameness and being of equal worth relate closely in Nor-wegian culture. In order to be of equal worth, one has tobe the same as. Moreover, shortly after a resident hadmoved in, the primary auxiliaries had authority in oralinteractions. The oral culture in this LTCF allowed theauxiliaries to some extent to control the informationflow of the new residents’ everyday needs. If the nurseswere preoccupied with other tasks, they depended onthe auxiliaries’ preliminary knowledge and insights. Thisis to some extent in line with Alcorn [44], who in a re-view of the relationship between registered nurses andhealthcare assistants found that “power plays material-izes through this relationship as healthcare assistants areplaced in powerful positions through controlling theflow of communication between registered nurses andpatients” (p 11).The nurses in our study functioned as gatekeepers as to

whether they would share medical information and know-ledge about the new resident with the other nursing staff.

The staff nurses also had the power to decide how theywanted to involve and supervise their staff. The findings inour study suggest that the auxiliaries at times did not workto the full of their scope. This appears to be in accordancewith Spilsbury & Meyer [45], who in their UK study foundthat the nurses had the power to control whether thehealth care assistant used their skills and experience to thefull. Still, the dynamic interactions between all the staffsuggest the strong interdependence among them. In ourprevious study [20], the task of writing the handwrittencare plans was delegated to the primary auxiliaries to beperformed shortly after the new resident had arrived. Thisindicate that the nurses supported the auxiliaries’ inde-pendent contributions. Alcorn and Topping [46] foundthat registered nurses supported the health care assistants’development, and that patient care was enhanced throughtheir development.However, some auxiliaries felt excluded since they

were not involved in the residents’ medical situation,and their intra-professional alliances seemed particularlyimportant to them. One way of understanding thismechanism is that the auxiliaries found a niche forthemselves within the organization, which protectedthem from the inherent organizational contradiction ofnot being involved in every aspect of the new resident,at the same time as being involved in everything [47].Historically, the development of professions aimed at se-curing and protecting exclusive areas of knowledge [48],and the nurses and physician in our study acted accordingto this tradition. In line with some studies [9,37,49], wefound that the professional cultures challenged spontan-eous inter-professional collaboration, which again influ-enced how the new residents were treated initially.Current political trends [9,37,50] aim at developing co-operative competence among all staff categories, also theunlicensed staff. This requires close collaboration betweendifferent levels of educational institutions, and betweenpractice institutions and educational institutions. Clark[51] found, by examining the interface between inter-professional practice and education in a Norwegiancontext, that there is a need to link developments in healthcare practice settings with those in education, “particularlyin such areas as continuing professional development,may be critical to the success of inter-professional practiceand inter-professional education” (p 31).Few professional groups work in most Norwegian

LTCFs and in this LTCF only nursing staff worked on aneveryday basis. That the physician only interacted withthe nurses also hampered cognitive diversity. In theirstudy of two Norwegian nursing homes, Jakobsen &Granebo [52], found that there is a need for wider multi-disciplinary teams to develop variations in the approachesto the older residents. The everyday extra activities pro-vided by some enthusiasts, seemed to move the new


residents towards a healthy transition. Yet, the findingsshow that they may overshadow the new residents’ com-plex needs, and well-meant activities from the staff ’s pointof view may have the adverse effect on some residents.Moving into LTCF is a dramatic change in a person’s life[15-17], and the person needs time to adjust to the newsituation and circumstances. However, unlike in mostcountries, the nurses performed hands-on care. This pro-vided diverse and complementary contributions in thespontaneous staff interactions. Moreover, the number ofnurses helped maintain a clear nurse identity, and seemedto support their self-confidence in their interaction withthe auxiliaries and assistants. Yet, the findings suggestthat the freedom the staff nurses had to manage theirunits in different ways, could at times delay the work ofthe facility nurse.The reading and writing of the daily reports and care

plans was inefficiently performed by many. The notionthat the computer program and its standards [53] froma social point of view serve as a “means for collabor-ation, shared meaning and far-reaching coordinationamong different health care professionals” (p 207) didnot seem to be the view of many staff. Spontaneous oralinteraction was the most useful. According to the WHO[37], inconsistent use and understanding of languagemay be a barrier to inter-professional collaborative prac-tice. Ellingsen [53] argues that standardization effortsmust target a level that is acceptable for those involved.Our findings suggest that the computer program did notconsider the different levels of staff, and the computercare plans did not generally seem to guide the daily careof the new residents, particularly not the licensed staffwho regarded the written care plans as rough guidelinesonly. This is in accordance with Lanham et al. [54], whoargue that complex adaptive systems contain unpredict-ability, and that care be conceptualized as provisionalplans for actions and not detailed plans to be strictlyfollowed.All these complex aspects of staff interactions appeared

to create stress among some, regardless of formal position,although our findings suggest that the assistants, particu-larly the weekend supply staff, were those who mostclearly appeared aloof from the rest of the staff. The focusof attention during negative stress shifts from interactionsto withdrawal [49], to preserve the individual’s dignity andself-esteem. Withdrawals may contribute to less nuancedcare because they mean fewer opportunities to verbalizequestions and actions, and thereby less awareness of one’sown and other’s work [55].

ConclusionsThe continuous and spontaneous staff collaborations werekey activities in supporting quality care in the transitionperiod. These interactions maintained the inclusion of all

staff present, staff flexibility, information flow to some ex-tent, and cognitive diversity, and the new resident’s emer-ging needs appeared met. Organizational structures, staff ’sformal position, and informal staff alliances were complexand sometimes appeared contradictory. Not all the staffwere necessarily included, and the new residents’ needsnot always noticed and dealt with. Paying attention tothe playing out of power in staff interactions appearsvital to secure a healthy transition process for the olderresidents.

Strengths and limitationsThe rich data from this small sample size study fulfil theintention of ethnographic studies to get in-depth insightinto a phenomenon. This approach is valuable since nostudies so far have investigated this phenomenon, andmay help extract ideas and directions in future studieswith larger samples and other designs. A future surveystudy of a representative sample of different staff employedin LTCFs could elucidate knowledge about this topic on agreater scale. Also, future studies need to link the develop-ment in health care practice settings during older residents’transitions into LTCF with different levels of educationalinstitutions, to explore and encourage inter-professionalcollaboration.

Competing interestsThe authors declare that they have no competing interests.

Authors’ contributionsME designed, collected, processed and analyzed the data, was responsiblefor the oversight of the study, and wrote the paper. SH together with MEdesigned, analyzed and read and revised drafts to the manuscript. BDcommented on the manuscript. GAE together with the others read andapproved the final manuscript.

Authors’ informationMarianne Eika RN, MCSs, PhD student. Norwegian University of Science andTechnology (NTNU), Department of Social Work and Health Science, Facultyof Social Sciences and Technology Management, Telemark UniversityCollege, Faculty of Health and Social Studies, and Center for CaringResearch – Southern Norway.Bjørg Dale RN, MSc PhD, is Associate Professor at Agder University, Departmentof Health and Nursing Sciences and Center for Caring Research – SouthernNorway.Geir Arild Espnes RN, MPsych, PhD, is Professor at the Norwegian Universityof Science and Technology (NTNU), Department of Social Work and HealthScience. Faculty of Social Sciences and Technology Management.Sigrun Hvalvik RN, MSc PhD, is Associate Professor at Telemark UniversityCollege, Faculty of Health and Social Studies and Center for CaringResearch – Southern Norway.

AcknowledgementsThe study has been funded by Center for Caring Research – SouthernNorway, Telemark University College. We are grateful to the nursing homestaff, management and residents for the opportunity to undertake this study.Olle Söderhamn who passed away in December 2013 participated in thedesign of this study.

Author details1Department of Social Work and Health Science, Faculty of Social Sciencesand Technology Management, Norwegian University of Science andTechnology (NTNU), 7491 Trondheim, Norway. 2Telemark University College,


Faculty of Health and Social Studies, Post box 203, NO-3901 Porsgrunn,Norway. 3Center for Caring Research, Telemark University College, Post box203, 3901 Porsgrunn, Norway. 4Department of Health and Nursing Sciences,Agder University, Campus Grimstad, Post box 509, N-4898 Grimstad, Norway.5Center for Caring Research – Southern Norway, Campus Grimstad, Post box509, N-4898 Grimstad, Norway.

Received: 27 October 2014 Accepted: 23 March 2015

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AbstractBackgroundMethodsResultsConclusions

BackgroundMethodsData collection, context and participantsData analysisEthical considerations

ResultsThe significance of formal and informal organizationIndividual actions and team workInformation flow

Interpersonal relationships and cultures of caringAlliances and collaborationThe privacy of caring

Professional hierarchy – different scopes of practiceHierarchy and responsibilityMonopoly of medical knowledge

DiscussionConclusionsStrengths and limitations

Competing interestsAuthors’ contributionsAuthors’ informationAcknowledgementsAuthor detailsReferences

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